Formal Inquiries

Seven Kings report and recommendations

Rail Safety and Standards Board (RSSB) has issued its formal inquiry report into the circumstances that led to a driver being hit by a train approaching Seven Kings, near Ilford, on Wednesday 28 January 2004.

The formal inquiry was convened under independent chairmanship and included representatives on the panel from the involved parties. As with all such inquiries the panel's task was to establish the immediate and underlying causes of the accident and make recommendations to prevent or reduce the risk of recurrence.

Sequence of events

A driver from another depot was covering an Ilford depot shift, when towards the end of the shift, he arrived with his train at Ilford Car Sheds nearly 20 minutes behind schedule. On arrival at 2118 hrs he already appeared agitated and argued when told that his train needed to be split. Still agitated, he finally left the depot, initially using the walking route to the drivers’ signing on point and authorised pedestrian exit.

He was expecting to travel as a passenger to Clacton where he was to sign off duty. He had earlier obtained agreement for the 2115 hrs Liverpool Street Station to Clacton, to make a special stop at Seven Kings Station (at approximately 2129 hrs) to pick him up. It is approximately 10 minutes walk from Ilford Car Sheds depot to Seven Kings Station via the authorised route.

The driver of the 2110 hrs Liverpool Street Station to Shenfield train told the inquiry that he had been generally braking early that shift, as it was the first time he had driven in snow. He had already started to brake for Seven Kings when his headlights picked up a person on the line wearing a high visibility vest and who had a bag slung over their right shoulder. After sounding his horn he moved the brake controller to the emergency position but unfortunately the train struck the person on the track. The person, who suffered severe injuries, was the driver who was making his way from the depot to Seven Kings station.

Conclusions

The formal inquiry panel concluded that the injured driver was using an unauthorised and clearly prohibited route between Ilford Car Sheds depot and Seven Kings Station and at the point of impact he was running along under a limited clearance bridge with his back to the oncoming train and his head down.

The panel also concluded that the primary underlying cause was that he had arrived at the depot very angry and irrational. The driver appeared to be determined to get home at the earliest opportunity but the panel was unable to determine the reasons.

Secondary underlying causes include a brief but heavy fall of snow in the London area that evening which caused some relatively minor delays and made underfoot conditions (particularly on or about the track) quite difficult. The snowfall appeared to reinforce the earlier weather forecasts that severe weather was likely which may have caused the driver some anxiety. Having to cover an Ilford shift, which finished later than his own depot shift appears to have placed him under some time pressure.

Recommendations

The report made one recommendation for the train operator to formulate and document guidance for issuing orders for trains to make unscheduled stops.

RSSB has issued a full copy of the report to each member of the Railway Group and the other organisations involved in the accident. All recipients of the report need to review the findings and recommendations and take actions where appropriate to address identified deficiencies within their own systems. RSSB will track the industry's response to this report.